Is Cognitive-Behavioral Therapy an Effective Treatment for Panic Disorder - Literature review Example

Running Head: COGNITIVE BEHAVIORAL THERAPY Is Cognitive-Behavioral Therapy an Effective Treatment for Panic Disorder? School Introduction Panic disorder is comprised of two categories: agoraphobia and without agoraphobia. The disorder is a chronic condition, of combined psychiatric symptoms that are common, and which, can also interfere with someone’s quality of life. Usually, the symptoms are presented by sudden recurrent panic attacks along with consistent fear of having further attacks, and overall fear about lifelong behavioral changes that can potentially derive from these attacks, lasting for approximately1 month or more (Davidoff, Christensen, Khalili, Nguyen, & IsHak, 2011; Roberson-Nay & Kendler, 2011). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) characterized panic attack as having at least 4 somatic or physical symptoms or behavioral symptoms, ranging from sweating, tachycardia, shakiness, dyspnea, nausea to feeling of “going crazy”, which are not reality based or related to any medical conditions, such as, hypothyroidism (American Psychiatric Association, 2000). Its prevalence in the community is estimated at 3.5% of the population, with an average age onset in the late 20s; it is more prevalent in women than men at two to three times the rate and often occurs following a stressful situation, thus, requiring frequent visits to the emergency departments and other health services, ranking panic disorder patients eight times more likely to use health services than non-panic disorder patients (Gros, Frueh, & Magruder, 2011; Manfro, Heldt, Cordioli, & Otto, 2008). Over the years, there have been countless studies suggesting that pharmacotherapy, such as antidepressants and benzodiazepines as being effective treatment options for panic disorder. However, nearly 50% of these patients taking the above drugs still complain of unrelieved symptoms, and about 30% reported feeling the same or worse (Manfro et al., 2008). Such low success rate for pharmacotherapy treatment of panic disorder is not comforting and demands a better alternative, that is cost-effective, sustainable and with limited to no side effects to patients (Hoffmann et al., 2007; Manfro et al., 2008). Various clinical studies have found Cognitive-behavioral therapy (CBT) to be an effective treatment alternative for panic disorder, with good short and long-term response for symptoms of panic attacks. Cognitive-behavioral therapy is a combination of two therapies ̶ Cognitive therapy (CT) and Behavioral therapy. Cognitive Therapy aims to help patients change maladaptive thoughts into more healthy and adaptive ones. Whereas, behavioral therapy’s main goal is to help change maladaptive behaviors into healthy behaviors (National Institute of Mental Health, 2013). (Hoffmann et al., 2007; Manfro et al., 2008). In this paper, we review literature to investigate the effectiveness of Cognitive-behavioral therapy as a treatment for panic disorder. Each CBT approach is described and reviewed for both short and long term efficiency results. CBT in combination with other treatment approaches are presented and assessed. The findings of the experts’ randomized controlled trials (RCTs) and some meta-analyses that show CBT’s usefulness are as well included in this paper. A literature review of data is gathered from medical journals and specialized books by respectable authors. Panic Disorder Panic disorder, with or without agoraphobia, can be a very incapacitating disorder that can significantly impair a person’s psychological, social, and occupational life. It is an anxiety disorder believed to be a learned fear of particular physical reactions. Agoraphobia is a behavioral response to anticipatory apprehension and overanxious avoidance (Craske & Barlow, 1993). Panic disorder frequently occurs in 26% of patients with agoraphobia and 33% of patients with social phobia, including pervasive anxiety on social contacts and performance (Roy-Byrne et al., 1999). Roughly one in three patients with panic disorder suffers depression, and one in five patients has suicidal inclinations (Weissman, Klerman, Markowitz, & Ouellette, 1989). Some patients with panic disorder resort to self-medication with alcohol, however the long-term incidence of alcohol and drug abuse is not considerably higher than in the general populace (Marshall, 1997). These patients exhibit a range of somatic and emotional difficulties, thus making them one of the most problematical and sustained patients in primary care. Symptomatic of panic disorder are panic attacks with episodes of manifold symptoms and a constant fear of having an attack. Attacks happen unexpectedly and normally last over 10 minutes, although the duration of attacks is inconsistent. Random occurrence can be one to a number of times weekly and may cause impediments with the patient’s regular activities and work (Roy-Byrne et al., 1999). Panic disorder is a chronic condition with attack frequencies and related symptoms such as hopelessness, and evasive behavior that may increase or diminish (Ham, Waters, & Oliver, 2005). Present studies prove a link between stressful life events (SLEs) and the trigger of panic attacks in adults eventually developing panic disorder with or without agoraphobia. SLEs incurred in households, such as complicated family problems, and SLEs from the workplace, such as being fired or unemployed, increase a person’s susceptibility to panic symptoms within 3 months of the episode. SLEs related to panic disorder onset comprise: (1) threats to primary relationships, such as interpersonal disagreement and separation or loss; (2) and health dangers, including physical illness. There is little study on the sequential connection between SLEs and panic disorder course or if SLEs cause aggravated panic disorder symptoms. Medical practitioners need a better understanding of the role of SLEs in panic disorder in order to anticipate factors that may worsen their patients’ condition (Moitra et al., 2011). Clinical Symptoms A distinct stage of strong fear or discomfort, in which at least four of the following symptoms suddenly develop and peak within 10 minutes: (1) palpitations, pounding heart, or increased heart pace; (2) sweating; (3) trembling or shaking; (4) feelings of breath shortage or suffocation; (5) choked feeling; (6) chest pain; (7) nausea or abdominal pain; (8) feeling dizzy, shaky, lightheaded, or pale; (9) feeling of unreality or feeling of being self-disconnected; (10) fear of losing control or going crazy; (11) preoccupied with death or illness; (12) numbness or tingling sensations; (13) chills or hot flushes (Diagnostic and Statistical Manual of Mental Disorders, 2000). Panic disorder patients with agoraphobia keep away from places or situations deemed as unsafe such as in public places. A crowded place aggravates a panic attack. Signs of agoraphobia consist of: (1) fearful of spending time alone; (2) frightened of places difficult to escape; (3) scared of losing control in a public place; (4) dependence on others; (5) feeling isolated or alienated from others; (6) feeling vulnerable; (7) feeling that the body is unreal; (8) feeling that the environment is illusory; (9) unreasonable anger or restlessness; (10) staying in the house for long durations of time (Taylor, Pollack, LeBeau, & Simon, 2008). Possible Complications 1. Possibility of substance abuse or misuse when persons with panic disorder attempt to conquer or suppress anticipatory anxieties by using alcohol or prohibited drugs; 2. High probability of unemployment, non-productive at work, complicated personal associations, problematic marriages and family lives; 3. Higher suicide rates for sufferers with both panic disorder and major depression than those with major depression only; 4. Severe restrictions of places to go and limited selection of friends when people with panic disorder with agoraphobia try avoidance of situations or places that are believed to trigger panic attacks (Taylor et al., 2008). Panic Disorder Treatment There are numerous alternatives for the management of panic disorder. Deciding on the best treatment is a mutual decision-making process between the patient and physician/therapist. Antidepressants Antidepressants are effective in the reduction of mild or severe panic attacks and the general improvement of quality of life in patients with panic disorder (Kumar, & Oakley-Browne, 2003). Two separate studies by Otto and colleagues (2001) on An effect-size analysis of the relative efficacy and tolerability of serotonin selective reuptake inhibitors for panic disorder and Bakker and associates (2002) on TCAs in the treatment of panic disorder: a meta-analysis, determined that selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are equally successful in decreasing panic severity and attack frequencies. Studies showed that 61 % of patients were panic-free following treatment of 1 ½ to 3 months, compared with 41 % of patients who self-control the attack. These studies vary on whether SSRIs are a more acceptable medication than TCAs. In a previous study by Boyer (1995) on Serotonin uptake inhibitors are superior to imipramine and alprazolam in alleviating panic attacks: A meta-analysis, it was verified that SSRIs are better than TCAs. On the other hand, the SSRIs’ advantages could have been exaggerated in the last study because of its failure to justify publication partiality due to a greater probability that little studies reporting no differentiation between management approaches are not made public (Ham, Waters, & Oliver, 2005). Benzodiazepines Benzodiazepines are as equally effective as anti-depressants in the reduction of panic symptoms and incidence of attacks. This type of medication is well tolerated, and gives a quick relief and improvement on the patient’s condition (Gould, Otto, & Pollack, 1995). Benzodiazepines, nonetheless, may have its downside as they may cause feelings of depression (van Balkom et al., 1997) which can be linked with the side effects during the medication and after termination of therapy (Kumar & Oakley-Browne, 2003). Moreover, benzodiazepines are not as successful as anti-depressants in some trial findings such as in overall performance (Clum, Clum, & Surls, 1993). Patients with panic disorder and co-existing comorbid depression issues cured with benzodiazepines have poorer results than patients using antidepressants (van Balkom, Nauta, & Bakker, 1995). Cognitive-behavioral therapy coupled with benzodiazepine medication can assist in the maintenance of reduced major panic symptoms even when benzodiazepine intake is later discontinued (Bruce, Spiegel, & Hegel, 1999). Cognitive-Behavioral Therapy Cognitive behavioral therapy (CBT) is a substitute and efficacious approach for the treatment of panic disorder and agoraphobic prevention. CBT comprises various techniques, such as applied relaxation, exposure in vivo, exposure via imagery, panic management, breathing control, cognitive restructuring and education about the nature of anxiety and panic (Ham, Waters, & Oliver, 2005). Cognitive-behavioral therapy is a combination of techniques taken from a range of cognitive and behavioral approaches and founded fundamentally on Peter Langs system representation of cognitive psychophysiology, centering on the relations of three systems influencing a person’s understanding of panic and anxiety: (1) physiological (lightheadedness, nausea, palpitation, sweating; (2) cognitive (fear of control loss or fear of going crazy); and (3) behavioral (prevention, frequency). CBT techniques are therefore aimed at all systems: (1) breathing control strategies intended to manage the physiological results of hyperventilation and progressive muscle relaxation to help in decreasing the harmful effects of muscle strain on anxiety; (2) Cognitive restructuring techniques that center on tragic anticipatory mistakes (for example, thinking that he/she will have a heart attack and die) and on misconceptions of harmless physical relations, intended to relieve problems in the cognitive system; (3) Psychoeducation which contradicts the myths of panic attacks (for example, panic attacks being linked with schizophrenia or heart disease) and serves as a type of stress immunization in the cognitive area; (4) Exposure to situations and events presumed to trigger an attack, which helps to lessen avoidance symptoms of the behavioral sphere (Craske & Barlow, 1993). The Different CBT Techniques Psychoeducation Psychoeducation informs patients with panic disorder of the nature of anxiety and panic. It breaks the fast surge of anxiety and panic into smaller components, and provides a motivation to pursue for more management interventions. The cause of anxiety and panic symptoms is identified and explained; the role of thoughts in sustaining the fear is established; and the role of avoidance and escape behaviors in prolonging fears and causing the confusion is likewise explained to the patient. Preliminary meetings with the therapist are carried out followed by repeated sessions throughout the treatment. It is essential to encourage the patient to do exposure exercises that unavoidably involve raise in anxiety intensities (Manfro et al., 2008). Anxiety Coping Techniques Increased oxygen in the blood resulting from hyperventilation and physiological reactions caused by inappropriate breathing patterns may lead to feelings of dizziness, asphyxiation, and tachycardia. Muscle tension may raise anxiety as well as physical reactions such as pains and paresthesias (abnormal sensations of tingling, numbness, or burning). Reactions such as these are comparable to a panic attack and can be lessened through proper breathing techniques and muscle relaxation. Breathing through the diaphragm is a technique that uses the muscles in the abdomen to control respiration. Progressive muscle relaxation exercises are relaxation practices that involve gradually and interchangeably tensing and relaxing muscles or the central muscle groups, this way the person feels the difference between tense and relaxed thus familiarizing the body to effectively loosen and relax. Relaxation and abdominal breathing techniques can be practiced one after another or separately, particularly in situations of anticipatory anxiety (Manfro, Heldt, & Cordioli, 2008; Heldt, Cordioli, Knijnik, & Manfro, 2008). However, in one study, it was substantiated that these anxiety coping techniques are unnecessary in panic disorder treatment (Schmidt, Wollaway-Bickel, Trakowski, Santiago, & Vasey, 2002), and that these techniques may bring about frantic attempts to control anxiety instead of facilitating the elimination of fears of panic symptoms. The eradication of such fears is the main intention of both cognitive and interoceptive exposure interventions (Manfro et al., 2008). Cognitive Techniques In patients with panic disorder, false and disastrous interpretations of bodily sensations of anxiety, and principles about depression and incapacity to cope with anxiety and panic are quite ordinary. A complete restructure of such devastating thoughts is the focal intention of cognitive therapy. It is of great significance that the patient recognizes the fundamental theories of the cognitive model and cognitive therapy − (1) that thoughts manipulate emotions and behavior, and (2) that anxiety and panic can be a result of wrong understanding of physical awareness. During the treatment, the therapist asks the patient to regard his thoughts simply as hypotheses or guesses, and then he is asked to monitor and evaluate his thoughts. After his evaluations, he should be able to identify and interpret these thoughts. Are these interpretations logical or distorted? The patient, with the guidance of the therapist, learns to recognize mistakes in his distorted interpretations and replace or modify his irrational thoughts (Manfro, Heldt, & Cordioli, 2008). Exposure Techniques 1. Interoceptive exposure Interoceptive exposure treatment repeatedly exposes patients to the physical sensations derived from physical exercises that may trigger panic symptoms. This Pavlovian-based conditioning model of panic approach involves a sequence of activities, for example purposely over-breathing to generate substantial consequences of hyperventilation, breathing through a straw while pressing the nose to produce feelings of being out of breath, spinning in a chair to feel dizzy, running in place to increase heart rate, or prolonged staring at ones hand to induce feelings of pointlessness. Such activities are repeated up to a time when habituation (decline in response to a stimulus after repeated presentations) of the anxiety reaction has been attained (Craske & Barlow, 1993). The goal of interoceptive exposure is to correct the disastrous interpretation of the patient’s bodily symptoms of preventative anxiety or panic attack. Repeated exposures prepare the patients to develop comfortable adjustment towards sensations. Exposure techniques are accomplished through deliberate provocation of symptoms through physical exercises. Patients are directly coached to become accustomed to sensations and in this process they learn to experience and identify these sensations as unusual or uncomfortable and not fear-provoking. Moreover, patients are taught to classify typical thoughts and disastrous interpretations linked with physical reactions and modify them. Interoceptive exposure exercises prepare the patient for in vivo exposure (Manfro, Heldt, & Cordioli, 2008). 2. In vivo exposure For sufferers of panic disorder, in vivo exposure is the chief intervention for conquering agoraphobic avoidance (Manfro, Heldt, & Cordioli, 2008). During the initial treatment, the therapist explains the evolving nature of avoidance, fear, and panic attacks: (a) The more patients escape situations that trigger their panic attacks, the more frightened they become; (b) The more frightened they become, the worse their panic attacks become; (c) And the worse their panic attacks become, the more they escape situations that trigger their panic attacks (Spett, 2008). The treatment exposes the patient to the situations or events that may rouse panic attacks. Primarily, the patient is asked to list down the fear-provoking places or events that he has avoided and to document the anxiety intensity and the involuntary thoughts that came up in these situations (Manfro, Heldt, & Cordioli, 2008). The list is then ranked in accordance with the complexity level of each confrontation. Beginning with the situation having the lowest anxiety intensity, In vivo exposure treatment is commenced. The exercise goes on until all anxiogenic situations are confronted and properly managed by the patient (Manfro et al., 2008). For complete efficacy of this approach, exposure should be extended, regularly repeated, and the anxiety level should always be taken into consideration throughout the exercise, and supervised by both the patient and the therapist (Powers, Smits, Leyro, & Otto, 2006). It is uncertain which element of CBT is more vital: cognitive therapy through identification of misconstrued feelings, psychoeducation of patients about panic and cognitive restructuring or behavior therapy through breathing exercises, relaxation and exposure. Nevertheless, the usefulness of exposure techniques alone is well ascertained in patients with panic disorder, predominantly in agoraphobic patients. The patient is constantly faced with the stimulus that rouses anxiety via imagery or in vivo (Westen & Morrison, 2001; Gould, Otto, & Pollack, 1995; Clum, Clum & Surls, 1993). It is recommended that a well-trained therapist in exposure techniques handle the patient. Self-Directed CBT If CBT treatment by a qualified therapist is not available, self-directed CBT through the use of videotapes and books have been confirmed useful in controlled studies (Gould  & Clum, 1995)  however it is not as effectual as standard CBT approaches (Sharp, Power, & Swanson, 2000).  Minimum sessions with a therapist are required to decrease panic symptoms (Febbraro, Clum, & Roodman, 1999). Clum’s Coping with Panic: A Drug-Free Approach to Dealing with Anxiety Attacks (1990) is a self-help book that has been studied in randomized controlled trials (RCTs). Alcohol Use and CBT Several male patients with panic disorder have a tendency to self-medicate with alcohol, which obstructs with CBT. The study A controlled trial of cognitive behavioral treatment of panic in alcoholic inpatients with comorbid panic disorder (Bowen, D’Arcy, Keegan, & Senthilselvan, 2000)  of alcoholic patients with panic disorder confirmed that CBT integration to a self-medicated alcohol-treatment plan has the same effect as alcohol treatment alone in decreasing panic symptoms. Antidepressants plus CBT There is confirmation that anti-depressants plus CBT is successful in the treatment of panic disorder although it is not established which treatment is better than the other. Some meta-analyses (Gould, Otto, & Pollack, 1995; Clum, Clum, & Surls, 1993) imply that CBT is more effective than antidepressants in reducing panic symptoms; on the other hand, some studies disagree on whether merging anti-depressants with CBT could improve results. In general, a combination of antidepressant plus a CBT technique gives the best advantage in meta-analyses of short-term studies (Bakker, van Balkom, Spinhoven, Blaauw, & van Dyck, 1998). In a RCT by Barlow’s group (2000) on the effectiveness of CBT plus imipramine or their combination for panic disorder treatment (Barlow, Gorman, Shear, & Woods, 2000), it showed that CBT plus antidepressants in the beginning was a little more helpful during therapy, however after every therapy was stopped, patients who used CBT alone or CBT plus placebo had better outcomes than patients undergoing combined CBT and antidepressants. Clinical Evaluation of CBT Implementation In a study performed by Westen and Morrison (2001), A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: an empirical examination of the status of empirically supported therapies, and by Gould and colleagues (1995), A meta-analysis of treatment outcome for panic disorder, the effectiveness of CBT in the improvement of panic symptoms and overall disorder was established. Most of the randomized controlled trials (RCTs) incorporated in these meta-analyses consisted of 8 to 15 sessions of CBT, although there have been reported cases of comparable success with only four sessions (Westen & Morrison, 2001).  Meta-analyses have determined that specialized cognitive therapy, behavior therapy, and combined CBTs are higher to general psychologically helpful psychotherapy in patients with panic disorder (Shear, Houck, Greeno, & Masters, 2001). In some CBT evaluations, 73% of patients were panic-free after 3 to 4 months CBT sessions, compared with only 27% of control patients (Westen & Morrison, 2001) and 46% of patients remained panic-free following two years of CBT treatment (Gould, Otto, & Pollack, 1995). These figures may seem impressive; however these account only for surveys in select populations that may not be reflective of the usual general practice patients. CBT seems to be successful over the long term, such as in trials ranging from 6 months to 9 years (Westen & Morrison, 2001; Gould, Otto, & Pollack, 1995; Milrod & Busch, 1996). Interpretations of these findings should however be cautious because the failure of patients to follow-up, the unfamiliar functions of other therapies in maintaining panic reductions, and the willingness of the patient to be treated may limit the consistency of CBT when applied single-handedly (Ham, Waters, & Oliver, 2005). A randomized, controlled study by Roy-Byrne and associates (2005) comparing CBT intervention to medication showed that the combined cognitive-behavioral therapy and pharmacotherapeutic intervention resulted in sustained and progressively increasing improvement compared with the standard treatment for primary care panic disorder, with considerably higher rates at all points of both the ratio of subjects remitted (20% versus 12% in 3 months; 29% versus 16% in 12 months) and responding (3 months, 46% versus 27% in 3months; 63% versus 38% in 12 months) and appreciably larger improvements in World Health Organization Disability Scale and Global Physical and Mental Health scales. Delivery of evidence-based CBT and medication using the Collaborative Care for Anxiety and Panic model and an inexperienced but CBT-trained behavioral health specialist is sufficient and remarkably more effectual than the standard care for primary care panic disorder. Another randomized clinical study performed by Craske and colleagues (2005) evaluated whether the integration of CBT improved results for panic disorder compared with medications alone in the primary-care setting. The addition of CBT resulted in statistically and clinically major improvements on anxiety sensitivity, social avoidance, and disability at 3 months. Moreover, patients treated with CBT in the first 3 months of the study were more improved at 12 months than patients treated with medications only during the first 3 months of the study. In the study, Therapists, Therapist Variables, and Cognitive-Behavioral Therapy Outcome in a Multicenter Trial for Panic Disorder, the therapists’ contribution to the outcome of CBT treatment was examined. 14 highly trained therapists participated in the Multicenter Collaborative Study for the Treatment of Panic Disorder. In the study, patients were randomly assigned to one of five groups: (1) CBT alone, (2) CBT plus placebo, (3) CBT plus imipramine, (4) imipramine alone, and (5) placebo alone, with each group guided by well trained therapists for CBT treatment. Therapist variables, such as age, gender, gender match, experience with CBT, training characteristics, orientation and personality characteristics, were also evaluated to determine which factor contributes to differences in CBT results. On the whole, therapists produced positive results in their cases; however, therapists notably varied in the amount of change among cases. The effectiveness of therapist impact on CBT results differed from 0% to 18%. Overall experience in performing psychotherapy was associated to outcome on some measures, while therapist variables were not. The findings imply that therapists effectively contribute to CBT positive outcomes for panic disorder (Huppert et al., 2001). Conclusion Overall, as evidenced by studies and randomized controlled trials by experts, cognitive behavioral therapy, either independently or in combination with medical treatment, is a very effective intervention for the treatment of panic disorder with or without agoraphobia, with a majority of patients experiencing considerable benefits and sustained and elevated improved conditions. Moreover, CBT is effective in treating PD with co-morbid issues, such as depression and generalized anxiety. CBT interventions, such as psychoeducation, cognitive restructuring, anxiety coping, breathing exercises, interoceptive exposure, and in vivo exposure, successfully reduce panic disorder symptoms in both the short and long terms. References American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Rev.). Washington DC: American Psychiatric Association Bakker, A., van Balkom, A. J., & Spinhoven, P. 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